The association between body mass index and musculoskeletal foot disorders: a systematic review

Nonoperative Management of High Ankle Sprains: A Case Series With ≥18-Year Follow-up

BACKGROUND

High ankle sprains are common athletic injuries and can be associated with long-term sequelae. Regardless of operative or nonoperative treatment, there is a paucity of data in the literature about the long-term outcomes of high ankle sprains.

HYPOTHESIS

Nonoperative treatment of high ankle sprains utilizing a standardized protocol will result in good long-term outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who experienced a high ankle sprain without radiographic diastasis of the syndesmosis were identified from a previous study database and contacted for long-term follow-up. All patients were high school or National Collegiate Athletic Association Division IA athletes at initial injury and were treated nonoperatively with the same standardized protocol. Patients completed a questionnaire that included documentation of any interim ankle injuries, 2 different patient-reported outcome scores, and ankle radiographs to conduct Kellgren-Lawrence scoring for ankle osteoarthritis.

RESULTS

In total, 76 cases in 74 patients were identified in the database. A total of 40 patients were successfully contacted, and 31 patients (24 collegiate and 7 high school athletes) with 33 high ankle sprains completed the survey (31/40; 77.5%). The mean age at follow-up was 45 years (range, 34-50 years), with a mean time from injury to follow-up of 25 years. Overall, 93.5% (n = 29) of the respondents were male, and 42% (n = 13) of the respondents reported an ipsilateral ankle injury since their initial injury, with 16% (n = 5) having ankle or Achilles surgery. The mean Patient-Reported Outcomes Measurement Information System-10 score was 53.4 (SD, 8.3; range, 37.4-67.7), PROMIS median (IQR), 54.1 (39.9, 68.3), and the mean Self-reported Foot and Ankle Score score was 42.7 (SD, 5.86). Follow-up ankle radiographs were obtained in 11 (35%) of the respondents; 27% had Kellgren-Lawrence grade >2 osteoarthritis, and 36% had signs of heterotopic ossification on imaging. The mean tibiofibular clear space was 4.5 mm, and the mean tibiofibular overlap was 7.15 mm, with 27% of patients demonstrating some tibiotalar narrowing.

CONCLUSION

At long-term follow-up, nonoperative management of high ankle sprains without diastasis on imaging was associated with acceptable patient-reported functional outcomes and low rates of subsequent ankle injuries. There was a high incidence of arthritis, but most cases were not clinically significant. This case series shows the natural history of nonoperatively treated high ankle sprains and may serve as a comparison for different management techniques in the future.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty

BACKGROUND

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA.

METHODS

A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS.

RESULTS

Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average.

CONCLUSION

Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA.

LEVELS OF EVIDENCE

Level III.

Effect of body mass index on acute postoperative complications following Total Ankle Arthroplasty (TAA)

BACKGROUND

Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI, age and sex on the acute postoperative complication rate after TAA.

METHODS

We retrospectively reviewed adult patients who underwent TAA between 2006 and 2021 from the NSQIP database. Using overweight patients as the reference BMI group, we utilized log-binomial models to estimate risk ratios on outcomes while adjusting for sex and age to investigate whether there were significant adjusted differences in complication rates among the BMI groups.

RESULTS

We found that, relative to overweight patients, there were no statistically significant differences in the risk of acute complications for underweight (BMI < 18.5) (P = .118), healthy weight (18.5≤BMI < 25) (P = .544), obese (30≤BMI < 40) (P = .930), or morbidly obese (BMI < 40) (P = .602) patients who underwent TAA. There were also no statistically significant differences in the risk of acute complications based on age category (P = .482,.824) or sex (P = .440) for TAA. Additionally, there were no significant differences between the BMI groups for either major complications (P = .980) or minor complications (P = .168).

CONCLUSION

Ultimately, we found that BMI, age, and sex did not lead to statistically significant differences in the risk of complications within 30 days postoperatively for TAA, even when stratified by major vs minor complications.

LEVEL OF EVIDENCE

Level III.

Relationship Between Obesity and Medial Longitudinal Arch Bowing

BACKGROUND

There have been reports about the association between obesity and the medial longitudinal arch (MLA) of foot. The purpose of this study is to investigate the change of various parameters related to the MLA according to obesity classification severity by the World Health Organization using weightbearing computed tomography (WBCT).

METHODS

WBCT data of the noninvolved side of patients presenting with unilateral foot and ankle problems or healthy candidates from September 2014 to October 2022 were extracted from a single referral hospital. Forty-four cases in each of 5 obesity classes were selected sequentially. Two orthopaedic surgeons measured foot and ankle offset, forefoot arch angle (FAA), hindfoot moment arm, percentage of uncoverage of the middle facet of the subtalar joint, talonavicular angle (TNA), navicular-medial cuneiform angle, medial cuneiform-first metatarsal angle, talus-first metatarsal angle (TMT1A), first tarsometatarsal subluxation (TMT1S), talonavicular coverage angle, navicular floor distance (NFD), and NFD per height. Positive values indicate plantar collapse. Intra- and interobserver reliabilities were assessed using intraclass correlation coefficients. One-way analysis of variance tests were performed for parametric data with equal variances, and Welch's test for unequal variances. Kruskal-Wallis test was performed for nonparametric data. Post hoc analysis was performed for statistically significant parameters. Correlation analysis between body mass index (BMI) and 12 parameters were performed using Pearson test.

RESULTS

Intraobserver and interobserver reliability were excellent, except for TMT1S. The TNA and TMT1A showed a statistically significant difference. FAA (r = -0.2), TNA (r = 0.182), TMT1A (r = 0.296), and NFD (r = -0.173) showed a statistically significant correlation with BMI.

CONCLUSION

In nonsymptomatic feet, we found that the talonavicular joint, as measured by the TNA, to be influenced by obesity classification. Obesity and increased BMI was associated with a negative influence on the MLA.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

The Medical Burden of Obesity and Overweight in the US Military: Association of BMI with Clinically Diagnosed Medical Conditions in United States Military Service Members

BACKGROUND

A high BMI is associated with various medical conditions, notably type 2 diabetes, cardiovascular disease, and mental health disorders. In the US military, BMI increased linearly between 1975 and 2015.

OBJECTIVE

This cross-sectional study investigated the associations between BMI and a comprehensive range of clinically diagnosed medical conditions (CDMCs) in US military service members (SMs).

METHODS

A stratified random sample of SMs (n=26,177) completed an online questionnaire reporting their height, weight, and demographic/lifestyle characteristics. Medical conditions for 6 mo before questionnaire completion were obtained from a comprehensive military electronic medical surveillance system and grouped into 39 CDMCs covering both broad (largely systemic) and specific medical conditions. BMI was calculated as weight/height2 (kg/m2). The prevalence of CDMCs was compared among normal weight (<25.0 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30 kg/m2) SMs.

RESULTS

After multivariable adjustment for demographic/lifestyle characteristics, higher BMI was associated with higher odds of a diagnosed medical condition in 30 of 39 CDMCs, with all 30 displaying dose-response relationships. The 5 major CDMCs with the largest odds ratios comparing obese to normal weight were endocrine/nutritional/metabolic diseases (OR=2.67, 95%CI=2.24-3.15), nervous system diseases (odds ratio [OR]=2.59, 95%CI=2.32-2.90), circulatory system diseases (OR=2.56, 95%CI=2.15-3.06), musculoskeletal system diseases (OR=1.92, 95%CI=1.76-2.09), and mental/behavioral disorders (OR=1.69, 95%CI=1.51-1.90). Compared with normal weight SMs, overweight or obese SMs had a higher number of CDMCs (1.8±1.9 vs. 2.0±2.0 and 2.5±2.3, mean ± standard deviation, respectively, P<0.01).

CONCLUSIONS

In a young, physically active population, higher BMI was associated with a host of medical conditions, even after adjustment for demographic/lifestyle characteristics. The US Department of Defense should improve nutrition education and modify other factors that contribute to overweight and obesity. This study demonstrates that the medical burden of obesity is substantial in overweight and obese SMs.

Association Between Musculoskeletal Pain and Studying Hours Among Medical Students in Jeddah, Saudi Arabia

Introduction Musculoskeletal (MSK) disorders are one of the common health issues affecting people of various ages. The main risk factors for musculoskeletal pain are age, obesity, gender, level of education, psychosocial factors, occupational factors, decreased mobility and flexibility, and common factors such as consuming TV and video games. College students, especially medical students, are at a higher risk of these complaints as they have longer hours of studying than most faculties due to the competitiveness of their specialty. The objective of this study was to identify the relationship between musculoskeletal pain and studying hours in medical students in Jeddah, Saudi Arabia, and to increase awareness of this problem. Methods This cross-sectional study was conducted in 2022. Data was collected using an online questionnaire. A total of 314 participants were included in this study. The demographic variables, studying hours, studying locations, and postures were collected and analyzed. Results A total of 314 medical students were included in this study. The majority were males (71.0%) and, the mean age was 22.05±2.13 years. Most of them were sixth-year students, and most of them reported studying between three and four hours (40.1%), with the most common studying location reported being the students' home or residence (79.3%). The number of daily studying hours had no significant effect on the occurrence of musculoskeletal problems. Conclusion There was no significant relationship between the number of studying hours and the MSK pain. Clinical trials could be used to evaluate the most effective approaches to alleviate MSK pain in medical students.

Association of Foot Symptoms With Decreased Time to All-Cause Mortality: The Johnston County Osteoarthritis Project

OBJECTIVE

Adults with foot symptoms (ie, pain, aching, or stiffness) may be at increased risk of reduced time to all-cause mortality. The purpose of this study was to evaluate whether foot symptoms are independently associated with all-cause mortality in older adults.

METHODS

We analyzed longitudinal data from 2613 participants from the Johnston County Osteoarthritis Project, a longitudinal population-based cohort of adults 45 years of age and older. Participants completed questionnaires at baseline to determine presence of foot symptoms and covariable status. Baseline walking speed was measured via an 8-foot walk test. To examine the association of foot symptoms with time to mortality, hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox regression models, adjusted for potential confounders.

RESULTS

We observed 813 deaths over 4 to 14.5 years of follow-up. At baseline, 37% of participants had foot symptoms, mean age was 63 years, mean body mass index was approximately 31 kg/m2 , 65% were women, and 33% were Black. Moderate to severe foot symptoms were associated with reduced time to mortality after adjustment for demographics, comorbidities, physical activity, and knee and hip symptoms (HR = 1.30, 95% CI 1.09-1.54). Importantly, this association was not modified by walking speed or diabetes.

CONCLUSION

Individuals with foot symptoms had an increased hazard of all-cause mortality compared with those with no foot symptoms. These effects were independent of key confounders and were not moderated by walking speed. Effective interventions to identify and manage at least moderate foot symptoms may reduce the risk of decreased time to mortality.

Foot morphology as a predictor of hallux valgus development in children

An excess of body weight can produce morphological changes in the feet of children. The aim of this study was to assess the morphological differences of the foot in children based on their body mass index and to determine the risk factors for the development of a hallux valgus in childhood and adolescence. One Thousand Six Hundred Seventy-Eight children (5-17 years) were classified as group with obesity, overweight, and normal weight. Lengths, widths, heights and angles of both feet was measured with a 3D scanner. The risk of developing hallux valgus was calculated. Group with overweight and obesity presented longer feet (p = 0.00), wider metatarsals (p = 0.00) and wider heels (p = 0.00). Arch height was lower (p > 0.01) in the group with obesity, and the hallux angle was greater in the group with normal weight (p < 0.05). The relative risk of a lateral hallux deviation increases with age, foot length and heel width (Exp (B) > 1). Children with overweight and obesity had longer and wider feet. The arch height was higher in children with overweight, and lower in children with obesity. Age, foot length, and heel width could be risk factors for the development of hallux valgus, while metatarsal width and arch height could be protective factors. Monitorization of the development and characterization of the foot in childhood as a clinical tool could help professionals to early identify the patients presenting risk factors and prevent future deformities and other biomechanical conditions in adulthood by implementing protecting measures.

Implications of obesity in patients with foot and ankle pathology

Obesity is a growing problem defined as a body mass index of greater than 30 kg/m². It is predicted that by 2030, 48.9% of adults will be classified as obese which expands surgical risk factors to a broad population while increasing healthcare costs at the same time in different socioeconomic groups. This specific population has been widely studied in multiple surgical fields and published studies have shown the implications in each of these fields. The impact of obesity on orthopedic surgical outcomes has been previously reported in several total hip and knee arthroscopy studies, with evidence indicating that obesity is strongly associated with an increased risk of post operative complications together with higher revision rates. In line with increasing interest on the impact of obesity in orthopedics, there has been a similar output of publications in the foot and ankle literature. This review article evaluates several foot and ankle pathologies, their risk factors associated with obesity and subsequent management. It provides an updated, comprehensive analysis of the effects of obesity on foot and ankle surgical outcomes, with the ultimate aim of educating both surgeons and allied health professionals about the risks, benefits, and modifiable factors of operating on obese patients.

Identifying Long-Term Trajectories of Foot Pain Severity and Potential Prognostic Factors: A Population-Based Cohort Study

OBJECTIVES

To identify distinct foot pain trajectories over 7 years and examine their associations with potential prognostic factors.

METHODS

Adults ages ≥50 years and registered with 4 general practices in North Staffordshire, UK were mailed a baseline health survey. Those reporting current or recent foot pain were invited to attend a research assessment clinic. Follow-up was by repeated postal surveys at 18, 36, 54, and 84 months. Distinct trajectories of foot pain were explored using latent class growth analysis (LCGA). Subsequently, identified trajectories were combined into most and least progressive groups, and covariate-adjusted associations with a range of prognostic factors were examined.

RESULTS

Of 560 adults with foot pain attending baseline research clinics, 425 (76%) provided data at baseline and 2 or more follow-up time points. LCGA for foot pain severity (0-10 numerical rating scale) identified a 4-trajectory model: "mild, improving" (37%); "moderate, improving" (33%); "moderate-severe, persistent" (24%); and "severe, persistent" (6%). Compared with individuals in more favorable (improving) pain trajectories, those in less favorable (persistent) pain trajectories were more likely to be obese, have routine/manual and intermediate occupations, have poorer physical and mental health, have catastrophizing beliefs, have greater foot-specific functional limitation, and have self-assessed hallux valgus at baseline.

CONCLUSIONS

Four distinct trajectories of foot pain were identified over a 7-year period, with one-third of individuals classified as having pain that is persistently moderate-severe and severe in intensity. The effect of intervening to target modifiable prognostic factors such as obesity and hallux valgus on long-term outcomes in people with foot pain requires investigation.

Impact of pain in other body regions on the foot-specific quality of life in patients with hallux valgus

OBJECTIVES

The purpose of this study was to clarify the prevalence of pain outside the foot, and to determine the associations of pain outside the foot with foot-specific quality of life (QOL) in patients with hallux valgus.

METHODS

Patients scheduled to undergo hallux valgus surgery were recruited. Patients answered whether they experienced disabling pain in 13 body regions other than the foot. Foot-specific QOLwas assessed using the Self-Administered Foot Evaluation questionnaire (SAFE-Q). Foot pain was quantified using the visual analogue scale (VAS). Patient characteristics, including age, sex, comorbidity, anxiety, and depression, were also surveyed. The association between pain elsewhere and the SAFE-Q and pain VAS scores were assessed using univariate and multivariate analyses.

RESULTS

Of 102 patients, 55 (54%) experienced pain other than the foot. All SAFE-Q subscale scores were lower, and pain VAS was higher in patients with pain elsewhere than in patients without. In the multivariate analysis, an increase in the number of pain regions was independently associated with a decrease in SAFE-Q scores and an increase in pain VAS.

CONCLUSION

More than half of the patients with hallux valgus experienced pain elsewhere. The presence of pain elsewhere was associated with poorer foot-specific QOL and severer foot pain.

Effect of Age and BMI on Sonographic Findings of Plantar Fascia

Biomechanical dysfunction of the foot is most common cause of plantar fascia disorder and obesity and increasing age are well-known risk factors. Due to being inexpensive and quick, ultrasound imaging techniques are considered the modality of choice to assess plantar fascia. The aim of this study was to investigate the effect of age and body mass index (BMI) on sonographic findings of plantar fascia in normal population. Ultrasonography was used to measure the plantar fascia thickness of 148 healthy adults (54 males, 36.5% and 94 females, 63.5%) during a period of one year. The age, BMI, and walking distance of each participant were recorded and statistically analyzed. The mean plantar fascia thicknesses at 0.5, 1.0, and 2.0 cm distal to the insertion of the plantar fascia were 1.76 ± 0.32 mm, 2.50 ± 0.50 mm and 2.11 ± 0.41 mm respectively. The mean plantar fascia thickness for individuals ≥45 years and BMI ≥25 were significantly higher (p < .001) compared to individuals <45 years and BMI <25. In a normal population, the thickness of the plantar fascia determined by ultrasound measurement was less than 3 mm. We recommend using the position 1.0 cm distal to the calcaneal insertion of the plantar fascia as the reference point for diagnosing plantar fasciitis. The thickness of plantar fascia was significantly increased with age and BMI whereas gender, walking activity, exercise and running did not seem to affect the plantar fascia thickness.

Overweight and obesity management in musculo-skeletal primary care: a survey of Australian health practitioners exploring &#x2018;the elephant in the room&#x2019

BACKGROUND

Overweight and obesity has a bi-directional association with the growing burden of musculoskeletal (MSk) dysfunction and pain. It seems inevitable that MSk practitioners will see increasing numbers of patients who are overweight and or obese and require this to be addressed as part of their management. Little evidence exists to describe the engagement of patients and their MSk practitioner in weight management as an adjunct or direct component of their intervention or therapy.

METHODS

A self-administered electronic survey was constructed with 13 items to collect self-reported data from Australian practitioners who have a focus on MSk management. The target group was from a multidisciplinary MSk network of 350 members.

RESULTS

A total of 204 completed surveys were analysed from respondents working in one of seven MSk- related professions. It was found that 70% of patients/clients seen by respondents were overweight or obese and that <18% of these patients had weight management included as part of their treatment.

CONCLUSIONS

Sixty percent of the respondents in this survey indicated that they do not include weight management as part of their practice despite 70% of their patients/clients being overweight and or obese. With the exception of Medical Practitioners and Exercise Physiologists, in this survey, the other therapists including Chiropractors, Osteopaths, Physiotherapists and Occupational Therapists, indicated that they lacked confidence, knowledge and methods to engage a systematic approach to weight management with their patients/clients.

Health-related quality of life is substantially worse in individuals with plantar heel pain

This study aimed to compare health-related quality of life (HRQoL) in people with and without plantar heel pain (PHP). This was a cross-sectional observational study that compared 50 adult participants with PHP to 25 participants without PHP who were matched for age, sex and body mass index (BMI). HRQoL measures included a generic measure, the Short Form 36 version 2 (SF-36v2), and foot-specific measures, including 100 mm visual analogue scales (VASs) for pain, the Foot Health Status Questionnaire (FHSQ), and the Foot Function Index-Revised (FFI-R). Comparisons in HRQoL between the two groups were conducted using linear regression, with additional adjustment for the comorbidity, osteoarthritis, which was found to be substantially different between the two groups. For generic HRQoL, participants with PHP scored worse in the SF-36v2 physical component summary score (p < 0.001, large effect size), but there was no difference in the mental component summary score (p = 0.690, very small effect size). Specifically, physical function (p < 0.001, very large effect size), role physical (p < 0.001, large effect size) and bodily pain (p < 0.001, large effect size) in the physical component section were worse in those with PHP. For foot-specific HRQoL, participants with PHP also scored worse in the VASs, the FHSQ and the FFI-R (p ≤ 0.005, huge effect sizes for all domains, except FHSQ footwear, which was large effect size, and FFR-R stiffness, activity limitation, and social issues, which were very large effect sizes). After accounting for age, sex, BMI and osteoarthritis, adults with PHP have poorer generic and foot-specific HRQoL.

Are children with obesity at school entry more likely to have a diagnosis of a musculoskeletal condition? Findings from a systematic review

BACKGROUND

Children with obesity at school entry are at increased risk of persistent obesity throughout childhood and adulthood. Little is known about associations with adverse health outcomes with onset during childhood including those affecting the musculoskeletal system. We examined the association between obesity present at school entry and adverse musculoskeletal diagnoses with onset during childhood.

METHODS

We searched three electronic databases to identify longitudinal studies published in English between January 2000 and June 2022 assessing associations between obesity measured at school entry (around age 5 years) and musculoskeletal diagnoses made before age 20 years. Two reviewers screened titles, abstracts and full-text using EPPI-Reviewer software. Bias and quality of eligible studies were appraised using The Quality Assessment tool for Observational Cohort and Cross-sectional studies and findings synthesised.

RESULTS

We identified four eligible studies from 291 unique records, three conducted in Spain and one in Scotland. These studies reported on 1 232 895 children (available data: 51.4% boys; none reported ethnic distribution) with study sample sizes ranging from <2000 to 600 000 and length of follow-up from 2 to 13 years. Quantitative synthesis of findings across these four studies was not possible due to differences in outcomes and effect sizes reported. Children with obesity at school entry were more likely to receive diagnoses of slipped capital femoral epiphysis, back pain, fractures and musculoskeletal complaints made in primary care settings. Included studies were assessed as of 'fair' to 'good' quality.

CONCLUSION

There is good to fair evidence to suggest children with obesity at school entry are more likely to receive a diagnosis of a musculoskeletal condition during childhood. Further research is needed to replicate these findings in ethnically diverse populations and to investigate whether these are causal associations. The implications of this for children's mobility and quality of life and future musculoskeletal health warrants further assessment.

Prevalence of flatfoot among young Korean males and the correlation among flatfoot angles measured in weight-bearing lateral radiographs

Flatfoot causes significant fatigue and pain while walking, and even asymptomatic flatfoot may increase the risk of metatarsal stress fracture during long-distance walking. While most studies have used physical examination or plantar footprints to diagnose flatfoot, a weight-bearing radiograph of the foot provides more objective data. However, data on the prevalence of flatfoot in Asian populations gathered in a nationwide cohort of a specific age group is lacking. We examined the prevalence of flatfoot among 19-year-old male Korean army recruits using a weight-bearing lateral radiograph and evaluated the correlation among flatfoot angles. A total of 560,141 19-year-old Korean males were examined at the regional Military Manpower Administration offices between April 2018 and April 2020. Weight-bearing lateral radiographs of the foot were obtained using an X-ray system while the subjects were standing on a table with their feet in a neutral position. Based on these radiographs, military orthopedic surgeons and radiologists measured the talo-first metatarsal angle (TMA) and calcaneal pitch angle (CPA) for flatfoot diagnosis. Mild flatfoot was diagnosed when the TMA ranged from 6 to 15° or the CPA was <17°, and moderate-to-severe flatfoot was diagnosed when the TMA was 15° or greater or the CPA was <10°. Pearson correlation coefficients and scatter plot matrix were used to evaluate the correlation among the flatfoot angles. Finally, we evaluated the relationship between body mass index (BMI) and flatfoot angles and compared the BMI in subjects with or without self-checked foot deformities including flatfoot and pes cavus. Of the 560,141 subjects, 16,102 (2.9%) were diagnosed as flatfoot, and 5265 (0.9%) were diagnosed with moderate-to-severe flatfoot. The coefficients between TMA and CPA ranged from 0.342 to 0.449 (all P values < 0.001), and those between the 2 sides of TMA and CPA were 0.709 and 0.746 (all P values < 0.001), respectively. BMI had a significant correlation with both TMA and CPA in subjects with flatfoot, and those with self-checked foot deformities had a significantly higher BMI than the group without foot deformities. The prevalence of total flatfoot and moderate-to-severe flatfoot in 19-year-old Korean males based on a weight-bearing lateral radiograph was 2.9% and 0.9%, respectively. The correlation coefficients between TMAs and CPAs showed a low degree of positive correlation. Higher BMI was associated with the likelihood of the presence of flatfoot.

International Foot and Ankle Osteoarthritis Consortium review and research agenda for diagnosis, epidemiology, burden, outcome assessment and treatment

OBJECTIVE

To summarise the available evidence relating to the diagnosis, epidemiology, burden, outcome assessment and treatment of foot and ankle osteoarthritis (OA) and to develop an agenda to guide future research.

METHOD

Members of the International Foot and Ankle Osteoarthritis Consortium compiled a narrative summary of the literature which formed the basis of an interactive discussion at the Osteoarthritis Research Society International World Congress in 2021, during which a list of 24 research agenda items were generated. Following the meeting, delegates were asked to rank the research agenda items on a 0 to 100 visual analogue rating scale (0 = not at all important to 100 = extremely important). Items scoring a mean of 70 or above were selected for inclusion.

RESULTS

Of the 45 delegates who attended the meeting, 31 contributed to the agenda item scoring. Nineteen research agenda items met the required threshold: three related to diagnosis, four to epidemiology, four to burden, three to outcome assessment and five to treatment.

CONCLUSIONS

Key knowledge gaps related to foot and ankle OA were identified, and a comprehensive agenda to guide future research planning was developed. Implementation of this agenda will assist in improving the understanding and clinical management of this common and disabling, yet relatively overlooked condition.

Pain catastrophising, body mass index and depressive symptoms are associated with pain severity in tertiary referral orthopaedic foot/ankle patients

Introduction

Patients with chronic foot/ankle pain are often referred for orthopaedic assessment. Psychological vulnerabilities influence pain states (including foot and ankle), therefore this study aimed to establish the prevalence and relative importance of compromised psychological health to perceived foot/ankle pain severity in people referred to an orthopaedic foot and ankle clinic with non-urgent presentations.

Methods

Patients with triaged non-urgent foot/ankle referrals to the Department of Orthopaedics at Gold Coast University Hospital were recruited over a 12-month period and completed the Manchester-Oxford Foot and Ankle Questionnaire which was the primary measure. Participants also completed questionnaires assessing their anthropometric, demographic and health characteristics (Self-Administered Comorbidity Questionnaire) as well as measures of health-related quality of life (EuroQol-5-Dimensions-5-Level Questionnaire and EQ Visual Analogue Scale) and psychological health (Center for Epidemiological Studies-Depression scale, Pain Catastrophizing Scale and Central Sensitization Inventory). Descriptive statistics were used to summarise participant characteristics and a hierarchical multiple linear regression was employed to establish the extent to which psychological variables explain additional variance in foot/ankle pain severity beyond the effects of participant characteristics (age, sex, body mass index (BMI)).

Results

One hundred and seventy-two adults were recruited ((64.0% female), median (IQR) age 60.9 (17.7) years and BMI 27.6 (7.5) kg/m²). Specific psychological comorbidities were prevalent including depressive symptoms (48%), central sensitisation (38%) and pain catastrophising (24%). Age, sex and BMI accounted for 11.7% of the variance in MOXFQ-index and psychological variables accounted for an additional 28.2%. Pain catastrophising was the most significant independent predictor of foot/ankle pain severity (accounting for 14.4% of variance), followed by BMI (10.7%) and depressive symptoms (2.3%).

Conclusions

This study demonstrated that specific psychological comorbidities and increased BMI are common in this cohort and that these factors are associated with the symptoms for which patients are seeking orthopaedic assessment. This knowledge should prompt clinicians to routinely consider the psychosocial components of patient presentations and develop non-operative and pre-operative treatment strategies which consider these factors with the goal of improving overall patient outcomes.

The Prognostic Utility of Electroencephalography in Stroke Recovery: A Systematic Review and Meta-Analysis

BACKGROUND

Improved ability to predict patient recovery would guide post-stroke care by helping clinicians personalize treatment and maximize outcomes. Electroencephalography (EEG) provides a direct measure of the functional neuroelectric activity in the brain that forms the basis for neuroplasticity and recovery, and thus may increase prognostic ability.

OBJECTIVE

To examine evidence for the prognostic utility of EEG in stroke recovery via systematic review/meta-analysis.

METHODS

Peer-reviewed journal articles that examined the relationship between EEG and subsequent clinical outcome(s) in stroke were searched using electronic databases. Two independent researchers extracted data for synthesis. Linear meta-regressions were performed across subsets of papers with common outcome measures to quantify the association between EEG and outcome.

RESULTS

75 papers were included. Association between EEG and clinical outcomes was seen not only early post-stroke, but more than 6 months post-stroke. The most studied prognostic potential of EEG was in predicting independence and stroke severity in the standard acute stroke care setting. The meta-analysis showed that EEG was associated with subsequent clinical outcomes measured by the Modified Rankin Scale, National Institutes of Health Stroke Scale, and Fugl-Meyer Upper Extremity Assessment (r = .72, .70, and .53 from 8, 13, and 12 papers, respectively). EEG improved prognostic abilities beyond prediction afforded by standard clinical assessments. However, the EEG variables examined were highly variable across studies and did not converge.

CONCLUSIONS

EEG shows potential to predict post-stroke recovery outcomes. However, evidence is largely explorative, primarily due to the lack of a definitive set of EEG measures to be used for prognosis.

Thirty Minutes Identified as the Threshold for Development of Pain in Low Back and Feet Regions, and Predictors of Intensity of Pain during 1-h Laboratory-Based Standing in Office Workers

This study with 40 office workers investigated (a) the effect of time spent standing on low- back and lower limb pain during a 1-h laboratory-based task; (b) the standing time after which a significant increase in pain is likely; and (c) the individual, physical and psychosocial factors that predict pain. The primary outcome was bodily location of pain and pain intensity on a 100-mm Visual Analogue Scale recorded at baseline and every 15 min. Physical measures included trunk and hip motor control and endurance. Self-report history of pain, physical activity, psychosocial job characteristics, pain catastrophizing and general health status were collected. Univariate analysis and regression models were included. The prevalence of low-back pain increased from 15% to 40% after 30 min while feet pain increased to 25% from 0 at baseline. The intensity of low-back and lower limb pain also increased over time. A thirty-minute interval was identified as the threshold for the development and increase in low-back and feet pain. Modifiable factors were associated with low-back pain intensity-lower hip abductor muscle endurance and poorer physical health, and with feet symptoms-greater body mass index and less core stability.

Effects of obesity and foot arch height on gait mechanics: A cross-sectional study

Foot arch structure contributes to lower-limb joint mechanics and gait in adults with obesity. However, it is not well-known if excessive weight and arch height together affect gait mechanics compared to the effects of excessive weight and arch height alone. The purpose of this study was to determine the influences of arch height and obesity on gait mechanics in adults. In this study, 1) dynamic plantar pressure, 2) spatiotemporal gait parameters, 3) foot progression angle, and 4) ankle and knee joint angles and moments were collected in adults with normal weight with normal arch heights (n = 11), normal weight with lower arch heights (n = 10), obesity with normal arch heights (n = 8), and obesity with lower arch heights (n = 18) as they walked at their preferred speed and at a pedestrian standard walking speed, 1.25 m/s. Digital foot pressure data were used to compute a measure of arch height, the Chippaux-Smirak Index (CSI). Our results revealed that BMI and arch height were each associated with particular measures of ankle and knee joint mechanics during walking in healthy young adults: (i) a higher BMI with greater peak internal ankle plantar-flexion moment and (ii) a lower arch height with greater peak internal ankle eversion and abduction moments and peak internal knee abduction moment (i.e., external knee adduction moment). Our results have implications for understanding the role of arch height in reducing musculoskeletal injury risks, improving gait, and increasing physical activity for people living with obesity.

A Systematic Review of Systematic Reviews on the Epidemiology, Evaluation, and Treatment of Plantar Fasciitis

The number of systematic review and meta-analyses on plantar fasciitis is expanding. The purpose of this review was to provide a comprehensive summary of reviews on the topic pertaining to plantar fasciitis, identify any conflicting and inconsistent results, and propose future research direction. A qualitative review of all systematic reviews and meta-analyses related to plantar fasciitis up to February 2021 was performed using PubMed, Embase, Web of Science, and the Cochrane Database. A total of 1052 articles were initially identified and 96 met the inclusion criteria. Included articles were summarized and divided into the following topics: epidemiology, diagnosis, and treatment. While the majority of reviews had high level of heterogeneity and included a small number of studies, there was general consensus on certain topics, such as BMI as a risk factor for plantar fasciitis and extracorporeal shockwave therapy as an effective mode of therapy. A qualitative summary of systematic reviews and meta-analyses published on plantar fasciitis provides a single source of updated information for clinicians. Evidence on topics such as the epidemiology, exercise therapy, or cost-effectiveness of treatment options for plantar fasciitis are lacking and warrant future research.

Is adiposity associated with back and lower limb pain? A systematic review

BACKGROUND

Back and lower limb pain have a major impact on physical function and quality of life. While obesity is a modifiable risk factor for musculoskeletal pain, the role of adiposity is less clear. This systematic review aimed to examine the relationship between both adiposity and its distribution and back and lower limb pain.

METHODS

A systematic search of electronic databases was conducted to identify studies that examined the association between anthropometric and/or direct measures of adiposity and site specific musculoskeletal pain. Risk of bias was assessed and a best evidence synthesis was performed.

RESULTS

A total of 56 studies were identified which examined 4 pain regions, including the lower back (36 studies), hip (two studies), knee (13 studies) and foot (eight studies). 31(55%) studies were assessed as having low to moderate risk of bias. 17(30%) studies were cohort in design. The best evidence synthesis provided evidence of a relationship between central adiposity and low back and knee pain, but not hip or foot pain. There was also evidence of a longitudinal relationship between adiposity and the presence of back, knee and foot pain, as well as incident and increasing foot pain.

CONCLUSIONS

This systematic review provides evidence of an association between both body fat and its central distribution and low back and knee pain, and a longitudinal relationship between adiposity and back, knee and foot pain. These results highlight the potential for targeting adiposity in the development of novel treatments at these sites.

Chronic Plantar Heel Pain Is Principally Associated With Waist Girth (Systemic) and Pain (Central) Factors, Not Foot Factors: A Case-Control Study

OBJECTIVE

To determine the independent associations of potential clinical, symptom, physical activity, and psychological factors with chronic plantar heel pain.

DESIGN

Case-control.

METHODS

We investigated associations by comparing 220 participants with chronic (more than 3 months in duration) plantar heel pain to 100 age- and sex-matched controls, who were recruited randomly from the electoral roll. Exposures measured were waist girth, body mass index, body composition, clinical measures of foot and leg function, physical activity via accelerometry, depression and pain catastrophizing, symptoms of prolonged morning stiffness anywhere in the body, and multisite pain. Data were analyzed using multivariable conditional logistic regression.

RESULTS

Waist girth (centimeters) (odds ratio [OR] = 1.06; 95% confidence interval [CI]: 1.03, 1.09), ankle plantar flexor strength (kilograms) (OR = 0.98; 95% CI: 0.97, 0.99), pain at multiple sites (pain at 1 other site: OR = 2.76; 95% CI: 1.29, 5.91; pain at 4 or more other sites: OR = 10.45; 95% CI: 3.66, 29.81), and pain catastrophizing status (none, some, or catastrophizer) (some: OR = 2.91; 95% CI: 1.33, 6.37; catastrophizer: OR = 6.79; 95% CI: 1.91, 24.11) were independently associated with chronic plantar heel pain. There were univariable but not independent associations with morning stiffness, first metatarsophalangeal joint extension range of motion, depression, and body mass index. There were no significant associations with physical activity or body composition (bioelectrical impedance analysis).

CONCLUSION

Waist girth, ankle plantar flexor strength, multisite pain, and pain catastrophizing, but not foot-specific factors, were independently associated with chronic plantar heel pain. Of these 4 factors, 3 (waist girth, multisite pain, and pain catastrophizing) were central or systemic associations. J Orthop Sports Phys Ther 2021;51(9):449-458. Epub 7 May 2021. doi:10.2519/jospt.2021.10018.

The Causal Relationship Between Body Mass Index and the Risk of Osteoarthritis

Objective

The study aimed to explore the causal effect of body mass index (BMI) on osteoarthritis.

Methods

The genome-wide association data of BMI and osteoarthritis were obtained via the Mendelian randomization (MR)-base platform. Single nucleotide polymorphisms (SNPs) significantly associated with BMI were identified and used as instrumental variables, and the causal relationship between BMI and osteoarthritis was examined using the two-sample MR research method. Three statistical methods including inverse-variance weighted (IVW) method, weighted median estimator, and MR-Egger regression were employed.

Results

A total of 79 SNPs significantly associated with BMI were identified in the study (P<5×10⁻⁸; linkage disequilibrium r² <0.1). Consistent association between BMI and osteoarthritis was observed when evaluated by different methods (IVW: odds ratio (OR) 1.028, 95% confidence interval (CI) 1.021–1.036; weighted median estimator: OR 1.028, 95% CI 1.019–1.037; MR-Egger regression: OR 1.028, 95% CI 1.009–1.046), which suggests that BMI is positively associated with increased risk of osteoarthritis. There was no evidence that the observed causal effect between BMI and the risk of osteoarthritis was affected by genetic pleiotropy (MR-Egger intercept 1.3×10⁻⁵, P=0.959).

Conclusion

The MR analysis provided the strong evidence to indicate that BMI might be causally associated with the risk of osteoarthritis.

Pressure pain thresholds in office workers with chronic neck pain: A systematic review and meta-analysis

OBJECTIVES

The purpose of this study was to (a) compare pressure pain threshold (PPT) values between office workers with chronic neck pain and asymptomatic controls; (b) establish reference PPT values in chronic neck pain; and (c) evaluate associations between PPTs and pain intensity, and disability.

METHODS

Seven English/Portuguese databases were searched for relevant literature. Studies investigating adult office workers (age >18 years) with chronic neck pain were included if PPTs were an outcome. The risk of bias was assessed using the Downs and Black checklist. Meta-analysis was conducted if a cluster contained at least two studies reporting the same PPTs.

RESULTS

Ten high quality, two low quality, and one poor quality studies were included. The meta-analysis revealed decreased PPT values in the upper trapezius, extensor carpi ulnaris, and tibialis anterior in office workers with chronic neck pain when compared with healthy workers, without a statistical difference (p > 0.05). The PPT reference value in the upper trapezius was 263 kPa (95% confidence interval [CI] = 236.35 to 289.70), and 365 kPa (95% CI = 316.66 to 415.12) for the tibialis anterior in office workers with chronic neck pain. No correlations were found between the upper trapezius PPT and pain intensity and disability.

CONCLUSION

This meta-analysis found that all the PPT measurements were not significantly reduced in office workers with chronic neck pain compared with healthy workers. These assumptions were based on a small sample of existing studies, and therefore further studies are necessary to quantify the differences in PPTs. Hypersensitivity PPT reference values are proposed for localized and extrasegmental sites in office workers with chronic neck pain.

Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain

Foot posture and ankle joint dorsiflexion have long been proposed to be risk factors for plantar heel pain, however body mass may be a confounder when investigating these factors. The aim of this study was to determine if clinical measures of foot posture and ankle joint dorsiflexion differ in adults with and without plantar heel pain after accounting for body mass. This was a cross-sectional observational study that compared 50 participants with plantar heel pain to 25 control participants without plantar heel pain who were matched for age, sex and body mass index. Foot posture was assessed using the Foot Posture Index and the Arch Index. Ankle joint dorsiflexion was assessed with a weightbearing lunge test with the knee extended and with the knee flexed. No significant differences (P < 0.05) were found between the groups for foot posture, whether measured with the Foot Posture Index or the Arch Index. Similarly, no significant differences were found in the weightbearing lunge test whether measured with the knee extended or with the knee flexed. Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain when body mass is accounted for. Therefore, clinicians should not focus exclusively on foot posture and ankle dorsiflexion and ignore the contribution of overweight or obesity.

Prevalence of postural musculoskeletal symptoms among dental students in United Arab Emirates

Background

The purpose of the present study was to determine the prevalence of neck, shoulder, and low-back pain and to examine factors associated with musculoskeletal pain (MSP) among dental students at Ajman University and Ras Al Khaimah College of Dental Sciences in United Arab Emirates (UAE).

Method

A cross-sectional study was conducted among dental students using an online questionnaire, which was a modified version of the Standardized Nordic questionnaire, focused on neck, shoulder and low-back pain in the past week and the past year.

Results

A total of two hundred and two dental students (out of 368) responded to the questionnaire. The majority were female 75.2%. The prevalence of MSP in at least one body site in the past week, and in the past year was 48.5 and 68.3% respectively. The factors significantly associated with MSP in at least one body site at any time were having history of trauma (P = 0.009), lack of exercise (P = 0.001), longer clinical sessions (P = 0.000), and higher BMI (P = 0.010).

Conclusion

The present study indicates that the prevalence of MSP among dental students in the UAE is high. Careful attention from dental colleges is needed to increase students’ awareness of this problem. This study contributed to better understanding of MSP among dental professionals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03887-x.

Pediatric unilateral spatial neglect: A systematic review

PURPOSE

Unilateral spatial neglect (USN), an inability to attend to one side of space or one's body, is commonly reported in adult stroke survivors and is associated with poor outcomes. USN has been reported in pediatric survivors of stroke, but its impact is unclear. The purpose of this systematic review was to summarize and evaluate the literature regarding USN in pediatric stroke survivors.

METHODS

PRISMA guidelines, Scopus, CINAHL, PubMed, and other relevant databases were searched with terms including "children", "stroke", and "unilateral neglect", with the ages of participants limited from to birth to 18 years. Data were extracted from studies on the clinical presentation of pediatric USN, the assessment of this condition, treatment options, or USN recovery.

RESULTS

A total of 18 articles met inclusion criteria. There were no current prevalence data available. USN presents similarly in children compared to adults. Several different USN assessments were used, however, there were little data regarding treatment options. Furthermore, the data suggest that not all children fully recover.

CONCLUSION

This systematic review reveals a lack of quality research to inform the assessment and treatment of children with USN. Although the literature spans decades, there remain no guidelines for standardized assessment or treatment. Similar to adults, paper-and-pencil testing may be less able to identify USN than functional assessments. It is likely that there are children who struggle with undetected USN-related deficits years after their injuries. With a rise of pediatric stroke survivors, there is a pressing need for clinicians to be educated about USN in children, clinical presentations, assessments, and treatments.

Foot Posture, Muscle Strength, Range of Motion, and Plantar Sensation in Overweight and Obese

The purpose of the study was to investigate the foot posture, ankle muscle strength, range of motion (ROM), and plantar sensation differences among normal weight, overweight, and obese individuals. One hundred and twenty-three individuals (42 normal weight, 40 overweight, and 41 obese) aged between 18 and 50 years participated in the study. Foot posture, ankle muscle strength, ROM, plantar sensation, and foot-related disabilities were evaluated. The relative muscle strength of left plantar flexors and invertors and light touch sensation of the left heel were significantly lower in obese individuals compared with overweight and normal weight (P < .016) individuals. Obese individuals had significantly reduced relative muscle strength of plantar flexors, dorsiflexor, and invertors, plantar flexion and inversion ROM in the left foot; and light touch sensation of the right heel compared with normal weight (P < .016) individuals. Foot Posture Index scores were significantly higher in obese individuals compared with overweight (P < .016) individuals. There were no significant differences in absolute muscle strength, vibration sensation, and foot-related disability scores among the 3 groups (P > .05). Obesity was found to have adverse effects on ankle muscle strength, ROM, and plantar light touch sensation. Vibration sensation was not affected by body mass index, and foot-related disability was not observed in obese adults.

Functional Evaluation and Pain Symptomatology of the Foot and Ankle in Individuals with Severe Obesity - Controlled Transversal Study

Objective  The present study aims to evaluate the prevalence of foot and ankle pain complaints, radiographic parameters, and functional performance in subjects with severe obesity (body mass index [BMI] > 40) who are candidates to bariatric surgery.

Methods  Forty severely obese patients were evaluated at a bariatric surgery outpatient facility. These severely obese subjects (BMI > 40) were divided into two subgroups: those with BMI < 50 (n = 24) and BMI > 50 (n = 16). These patients were compared with a control group of 42 volunteers with a mean BMI value of 24. The following parameters were assessed: foot pain (according to the visual analog scale [VAS]), functional performance (according to the American Orthopeadic Foot and Ankle Society [AOFAS] scale, including forefoot, midfoot and hindfoot domains), age, gender, hallux metatarsal-phalangeal angle, hallux intermetatarsal angle, talocalcaneal angle, calcanean pitch angle and Meary angle.

Results  Incidence of foot pain was higher in the severely obese group compared with the control group ( p  < 0.0001; odds ratio [OR]: 4.2). Functional performance according to the AOFAS scale was lower in obese subjects compared with the control group ( p  < 0.0001; OR for hindfoot, 4.81; OR for midfoot, 3.33).

Conclusion  The incidence of foot pain was higher in the group of severely obese patients compared with the control group. According to the AOFAS scale, functional forefoot, midfoot and hindfoot performance was worse in severely obese individuals.

Thai version of the foot function index: a cross-cultural adaptation with reliability and validity evaluation

Background

The study aimed to translate the foot function index (FFI) questionnaire to Thai and to determine psychometric properties of the questionnaire among individuals with plantar foot complaints.

Methods

The Thai version of the FFI (FFI-Th) was adapted according to a forward and backward translation protocol by two independent translators and analyzed by a linguist and a committee. The FFI-Th was administered among 49 individuals with plantar foot complaints to determine internal consistency, reliability, and validity. Cronbach’s alpha and the Intraclass Correlation Coefficient (ICC_3,1) were used to test the internal consistency and test-retest reliability. The Principal Component Analysis with varimax rotation method was used to test the factor structure and construct validity. Furthermore, the criterion validity was tested using Pearson’s correlation coefficient (r_p) between the FFI-Th and the visual analogue pain scale (pain-VAS) as well as the EuroQol five-dimensional questionnaire (EQ-5D-5L).

Results

The FFI-Th showed good to excellent internal consistency and test-retest reliability in the total score, pain, disability, and activity limitation subscales. The Principal Component Analysis produced 4 principal factors from the FFI-Th items. Criterion validity of the FFI-Th total score showed moderate to strong correlations with pain-VAS and EQ-5D-5L, and EQ-VAS scores.

Conclusion

The FFI-Th was a reliable and valid questionnaire to assess the foot function in a Thai population.

Trial registration

NCT03161314 (08/05/2017).

Body weight-dependent foot loads, assessed in terms of BMI and adiposity, in school-aged children: a cross sectional study

Whereas inherently vulnerable structure of both a child's and an adolescent's foot, characteristic for its dynamic, developmental stage, is particularly exposed to numerous environmental factors, excessive body weight gain may potentially become a crucial causal factor, bringing on a cascade of adverse effects throughout the body, e.g. disorders of the skeletal-articular system, gait alterations, abnormally excessive loading of the plantar zones of the foot, and consequently serious postural defects, especially in later life. Since obesity, aptly dubbed the scourge of the 21st c., directly impacts the way the foot biomechanics are developed, whereupon the actual paradigm of foot loading becomes subject to numerous, adverse modifications, the present study focused on gaining an in-depth insight into prevalent association of BMI, adipose tissue content in body composition, and the actual distribution of foot loads in the school-aged children. Since body weight, the simplest anthropometric indicator, is actually non-indicative of the proportion of adipose tissue within body composition, a number of modern, non-invasive diagnostic methods were applied by the investigators to have this deficit effectively addressed, inclusive of comprehensively mapping out the actual load distribution in the plantar zones of the foot.

Factors associated with musculoskeletal symptoms and heart rate variability among cleaners - cross-sectional study

BACKGROUND

The professionals who perform cleaning activity constitute a major economic sector in Brazil. Cleaners may develop health problems related to the musculoskeletal and cardiovascular systems. It is necessary to understand the working and health conditions of cleaners in Brazil. Thus, the aim of this study was to identify factors associated with musculoskeletal symptoms and heart rate variability (HRV) among cleaners.

METHODS

A cross-sectional study conducted at a public higher education institution with 45 outsourced cleaners following approval from the institutional ethics committee. The participants answered a questionnaire addressing sociodemographic, occupational and health data, the Nordic Musculoskeletal Questionnaire, the Physical Activity Questionnaire (work and leisure) and the short version of the Copenhagen Psychosocial Questionnaire. Clinical data (height, body mass, waist-to-hip ratio and blood pressure) and heart rate variability (HRV) were also collected. Logistic and linear regression models were created to identify factors associated with symptoms and HRV.

RESULTS

The sample consisted of women (100%) predominantly older than 50 years of age (44%), without a conjugal life (64%), with three or more children (59%), low educational level (58%) and who worked less than 12 months at the company (87%). Systemic arterial hypertension (23%) was the most reported health problem. The highest frequency of musculoskeletal symptoms was identified in the lower limbs (ankles/feet: 31% in the previous 12 months and 24% in the previous 7 days; knees: 31% in the previous 12 months and 20% in the previous 7 days). Moreover, the workers reported not practicing physical activity during leisure time (84%). Psychosocial aspects indicated health risks for the dimensions "influence at work" (74%), "burnout" (59%) and "stress" (52%). Associations were found between ankle/foot symptoms and body mass index, shoulder symptoms and predictability, and knee symptoms and self-rated health and burnout. HRV indices were associated with age.

CONCLUSIONS

This study outlined the profile of female cleaners and identified risk factors. The workers exhibited musculoskeletal symptoms, which were associated with the body mass index and some psychosocial factors. HRV indices were associated with age. Thus, health promotion and prevention measures should be taken to benefit this population of workers.

Three-Dimensional Ankle Exercise with Combined Isotonic Technique for an Obese Subject with Plantar Fasciitis: A Case Study

Background and objectives: Obese people have many foot-related disorders and plantar fasciitis (PF) is the most common disorder among them. However, research on the role of therapeutic exercises in PF is lacking and there is no evidence to suggest its benefits. As such, a further insight into therapeutic exercises is needed within this group. This case study investigated the effect of three-dimensional (3D) ankle exercises using a combined isotonic (CI) technique on function and balance in an obese subject with PF. Material and methods: The subject in this study was a 28-year-old obese woman who was diagnosed with PF by an orthopedic surgeon. A 3D ankle exercise program was commenced three times a week for 15 min over 4 weeks. The evaluations were conducted at five intervals: pre-test, and at 1, 2, 3 and 4 weeks from the initiation of the intervention. The tests were conducted in the following order: the patient-specific functional scale test (PSFS), an ultrasound of the plantar fascia, the heel pressure and balance test, the pressure pain threshold (PPT), and the 4-way ankle strength test. Results: The mean score of the PSFS test reduced by 70.55% after 4 weeks of the intervention. The thickness of the plantar fascia and heel pressure measured during single-leg standing decreased by 6.67% and 10.37%, respectively, after 4 weeks of the intervention. The anteroposterior and medial-lateral balance ability showed improvements of 8.29% and 8.61%, respectively, after 4 weeks of the intervention. The PPT improved by 38.01% after 4 weeks of the intervention. In the 4-way ankle strength test, dorsiflexion, plantar flexion, inversion, and eversion increased by 14.46%, 9.63%, 4.3% and 13.25%, respectively, after 4 weeks of the intervention. Conclusion: 3D ankle exercises utilizing the CI technique were shown to be effective in improving foot function, pressure pain, and muscle strength in dorsiflexion and inversion in an obese patient with PF.

Functional outcome after the nonsurgical treatment for adolescent spasmodic valgus foot

BACKGROUND

Adolescent spasmodic valgus foot is usually associated with resistant pain and deformity. It shows controversy regarding its incidence, etiology, and treatment. Our study aimed to evaluate the functional outcome after the nonsurgical treatment for such condition.

METHODS

This study included 50 planovalgus feet secondary to peroneal or peroneo-extensor spasm in 33 adolescents with a mean age of 14 ± 2.8 years. The procedure included foot manipulation under general anesthesia, sinus tarsi injection with corticosteroids, and a walking cast in the neutral position. Patients were evaluated functionally (using the American Orthopedic Foot and Ankle Society (AOFAS)) and radiologically before the procedure, after cast removal, and 3, 9, and 18 months later with special attention given for recurrence during the follow-up period with a mean duration of 22.5 ± 3.5 months.

RESULTS

Once general anesthesia had been conducted, the deformity was corrected without any manipulation, and full passive inversion could be easily obtained in 26 feet, the deformity was corrected only after manipulation, and full passive inversion had been obtained in 14 feet, while 10 feet remained stiff even after manipulation. The mean AOFAS score was significantly improved ( p < 0.001) from 40.9 ± 3.5 at presentation to 73.56 ± 5.2 at the last follow-up in which 12 feet was painless and freely mobile and 24 feet had partial relapse, while 14 feet had complete relapse.

CONCLUSION

The nonsurgical treatment for adolescent spasmodic valgus foot could be a simple and effective treatment. Apart from limited complete recurrence, the overall functional outcome was satisfactory. Level of evidence: type IV case series.

Work-related musculoskeletal disorders among Saudi orthopedic surgeons: a cross-sectional study

INTRODUCTION

Studies have addressed the issue of increasing prevalence of work-related musculoskeletal (MSK) pain among different occupations. However, contributing factors to MSK pain have not been fully investigated among orthopaedic surgeons. Thus, this study aimed to approximate the prevalence and predictors of MSK pain among Saudi orthopaedic surgeons working in Riyadh, Saudi Arabia.

METHODS

A cross-sectional study using an electronic survey was conducted in Riyadh. The questionnaire was distributed through email among orthopaedic surgeons in Riyadh hospitals. Standardized Nordic questionnaires for the analysis of musculoskeletal symptoms were used. Descriptive measures for categorical and numerical variables were presented. Student's t-test and Pearson's χ2 test were used. The level of statistical significance was set at p ≤ 0.05.

RESULTS

The response rate was 80.3%, with a total number of 179 of Saudi orthopaedic surgeons (173 males and six females). Of our sample, 67.0% of the respondents complained of having MSK pain. The most commonly reported MSK pain was lower back (74.0%), followed by neck (58.2%). Age and body mass index were implicated in the development of more than one type of MSK pain. Increased years of experience (≥ 6 years) was linked to shoulder/elbow, lower back, and hip/thigh pain. Smoking is widely associated with lower back pain development, whereas physicians who do not smoke and exercise regularly reported fewer pain incidences. Excessive bending and twisting during daily practice have been correlated with increased neck pain.

CONCLUSION

MSK pain was found to be common among Saudi orthopaedic surgeons. Further extensive research should be conducted to understand and analyze the risk factors involved and search for possible improvements to avoid further complications. However, ergonomics education during surgical training could be effective at modifying behaviors and reducing MSK pain manifestations.

Body Fat and Muscle Mass in Association with Foot Structure in Adolescents: A Cross-Sectional Study

Prior studies have investigated associations between body mass index (BMI) and foot structure; however, these studies are limited only to the evaluation of the longitudinal arch of the foot and do not evaluate associations with body composition. Therefore, this study examined associations between body fat percentage (BFP) and muscle mass percentage with foot structure in adolescents. This study was conducted with 158 healthy subjects aged from 11 to 13 years. Body fat percentage and muscle mass percentage were estimated using bioelectrical impedance analysis. A podoscope was used to calculate Clarke's angle (CL), the Wejsflog index (WI), hallux valgus angle (ALPHA), and the angle of the varus deformity of the fifth toe (BETA). Lower values of CL were found in participants with excessive BFP (p = 0.021). No differences were observed in the values of the Wejsflog, ALFA or BETA indices between normal and excessive BFP groups. Participants with the lowest muscle mass percentage were significantly more likely to have lower values of CL and WI (p = 0.014 and p < 0.001, respectively). Excess BFP appeared to have a significant effect on the longitudinal arch and low muscle mass percentage on the longitudinal and transverse arches of the foot in adolescents. There was no association between fat and muscle content with positions of the big and fifth toes.

Prevalence of Foot Pain Across an International Consortium of Population-Based Cohorts

Objective

Despite the potential burden of foot pain, some of the most fundamental epidemiologic questions surrounding the foot remain poorly explored. The prevalence of foot pain has proven to be difficult to compare across existing studies due to variations in case definitions. The objective of this study was to investigate the prevalence of foot pain in several international population‐based cohorts using original data and to explore differences in the case definitions used.

Methods

Foot pain variables were examined in 5 cohorts: the Chingford 1000 Women Study, the Johnston County Osteoarthritis Project, the Framingham Foot Study, the Clinical Assessment Study of the Foot, and the North West Adelaide Health Study. One question about foot pain was chosen from each cohort based on its similarity to the American College of Rheumatology pain question.

Results

The precise definition of foot pain varied between the cohorts. The prevalence of foot pain ranged from 13% to 36% and was lowest in the cohort in which the case definition specific to pain was used, compared to the 4 remaining cohorts in which a definition included components of pain, aching, or stiffness. Foot pain was generally more prevalent in women and obese individuals and generally increased with age, with the prevalence being much lower in younger participants (ages 20–44 years).

Conclusion

Foot pain is common and is associated with female sex, older age, and obesity. Estimates of the prevalence of foot pain are likely to be affected by the case definition used. Therefore, in future population studies, the use of consistent measures of data collection must be considered.

Effects of insoles adapted in flip-flop sandals in people with plantar fasciopathy: a randomized, double-blind clinical, controlled study

OBJECTIVE

To evaluate the effects of insoles adapted into flip-flop sandals on pain and function in individuals with plantar fasciopathy (PF).

DESIGN

Randomized, double-blind controlled study.

SETTING

Physiotherapy clinic of the Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Santa Cruz, Brazil.

SUBJECTS

Sixty-six patients of both genders with PF were randomized into two groups: sandal insole group (SI; n = 34), which received a pair of custom flip-flop sandals with insoles covered with smooth synthetic leather; and plain sandal group (PS; n = 32), which received an identical pair of flip-flop sandals, but without the insoles.

INTERVENTIONS

Patients were instructed to wear the flip-flops for 12 weeks for at least 4 hours/day.

MAIN MEASURES

Pain (visual analogue scale-VAS) in the morning and at the end of the day were considered primary outcomes. Function (Foot Function Index-FFI and Foot and Ankle Ability Measure-FAAM) and functional capacity (6-minute walk test-6MWT) were considered secondary outcomes. The outcomes were evaluated at baseline and immediately after the intervention by a blind assessor.

RESULTS

Between-group differences were observed in terms of morning pain (mean difference (MD) = -1.82 cm; 95% confidence interval (CI) = -3.3 to -0.3; P = 0.016) and function (MD = -0.10; 95% CI = -0.19 to -0.01; P = 0.023) after the interventions with the SI group showing superior improvements in comparison to the PS group.

CONCLUSION

The use of insoles adapted in flip-flop sandals for 12 weeks was effective at improving pain and function in individuals with PF.

LEVEL OF EVIDENCE

1b.

Low Back Pain Among Medical Students: A Burden and an Impact to Consider!

STUDY DESIGN

Prospective study.

OBJECTIVE

Determine risk factors and consider impact of low back pain for medical students.

SUMMARY OF BACKGROUND DATA

Low back pain (LBP) is one of the most prevalent complaints among students. The vulnerability of medical students due to stress and numerous hours of studying and training makes them at risk of LBP.

METHODS

We submitted an online self-administered modified version of the Standardized Nordic Questionnaire to 1800 medical students from 2nd to 6th year from December 2017 to March 2018.

RESULTS

A total of 1243/1800 (68.9%) students responded to our survey. Mean age was 23.3 ± 2.9 years ranging from 18 to 44 years. 835 (72.1%) students reported suffering from LBP. In multivariate analysis with logistic regression analysis model, the third year of medical studies (odds ratio [OR]: 0.558, 95% confidence interval [CI] 0.387-0.805; P = 0.002) was identified as an independent prognostic factor of LBP. Moreover, exercising weekly (OR: 1.835, 95% CI 0.933-2.5; P = 0.01) and walking at least 30 minutes a day (OR: 1.458, 95% CI 1.129-1.876; P = 0.01) significantly improve LBP. LBP generate higher monthly consumption of an analgesic (OR: 32.8, 95% CI 4.271-252.2; P < 0.001). Finally, LBP had a severe repercussion on student work (OR: 18.89, 95% CI 10.122-35.253; P < 0.0001), on the quality of sleep (OR: 12.162, 95% CI 6.917-21.386; P < 0.0001) and on their personal life (OR: 12.343, 95% CI 5.681-26.8; P < 0.0001).

CONCLUSION

Medical students reported high prevalence of LBP with severe consequences. Our educational perspective is to identify the risk factors of LBP, fight them, to improve the medical student' work, and welfare.

LEVEL OF EVIDENCE

3.

Managing the patient with heel pain

Heel pain presents frequently to primary care, commonly affecting athletic and elderly patients. Its presentation can be a common source of confusion for clinicians given the wide variety of differential diagnoses and the similarities in presenting symptoms and signs. This review classifies heel pain according to site of pain and explores the common pathologies clinicians may encounter. A brief summary of common imaging modalities used is provided. The literature is reviewed to guide evidence-based practice and to provide a framework to help clinicians investigate and manage heel pain before onward referral for specialist intervention. A linked article detailing the imaging of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.192 ).

Efficacy and safety of electroacupuncture plus warm needling therapy for heel pain: study protocol for a randomized controlled trial

BACKGROUND

Heel pain is a common foot disorder that causes pain and functional limitations. The prevalence of disabling foot pain will increase as the population ages. Previous studies have reported the positive therapeutic effects of electroacupuncture, warm needling, or the combination of both for heel pain but with limitations in the study methodologies. The current study is a rigorously designed randomized controlled trial that aims to evaluate the clinical efficacy and safety of electroacupuncture plus warm needling therapy in patients with heel pain.

METHODS/DESIGN

The study protocol describes a prospective, open-label, parallel-group, randomized controlled trial to be conducted in Hong Kong. Eighty patients aged 50-80 years who have reported heel pain and first-step pain equal to or exceeding 50 mm on the 100-mm visual analog scale (VAS) will be recruited. They will be randomly assigned (1:1 ratio) to the electroacupuncture plus warm needling therapy (i.e., treatment) group or the waitlist (i.e., control) group. The treatment group will undergo six treatment sessions in 4 weeks. The control group will receive no treatment during the study period. The primary outcome measure is a mean change in the first-step pain VAS score from the baseline to week 4. Secondary outcome measures include a mean change in first-step pain VAS score from the baseline to week 2, a mean change in Foot Function Index (FFI) subscale scores and the total score from the baseline to week 2 and week 4, and patients' self-reported level of improvement at week 4. Additional week 8 follow-up assessments with first-step pain VAS and FFI measurements will be arranged for the treatment group. Any adverse events will be recorded throughout the study to evaluate safety. An intention-to-treat approach will be used to analyze the study results.

DISCUSSION

This study will provide evidence on the efficacy and safety of electroacupuncture plus warm needling therapy as an alternative treatment method for heel pain. The findings will determine whether the treatment protocol is efficacious in relieving pain and improving foot function among older adults with heel pain. The study will also provide information for subsequent large-scale randomized controlled trials in the future.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1800014906 . Registered on 12 February 2018.

Management of musculoskeletal foot and ankle conditions prior to public-sector orthopaedic referral in South Australia

Background

Foot and ankle pain is common in the Australian adult population. People with musculoskeletal foot and ankle conditions are often referred for surgical opinion, yet how patients are managed prior to referral is largely unknown. The aim of this study was to determine the characteristics and management of patients with musculoskeletal foot and ankle complaints prior to public-sector orthopaedic referral in South Australia.

Methods

People with non-urgent foot or ankle complaints were recruited over a 12-month period from the waiting-lists of three tertiary hospitals in Adelaide, Australia. Participants completed a questionnaire on their medical history, duration and location of their foot or ankle complaint, diagnosis of their condition, previous treatment and medical imaging. The Manchester-Oxford Foot and Ankle Questionnaire, and the EuroQol-5D-5 L measured foot/ankle pain severity and health-related-quality-of-life (HRQoL). Descriptive statistics were generated for sample demographics, medical history and foot/ankle symptoms. Multivariable regressions were used to explore factors associated with foot/ankle pain severity and whether participants considered an operation necessary.

Results

Two hundred and thirty-three adults returned questionnaires, with a survey response rate of 38.4% (66.1% female, median age 57.7 years IQR 18.5, BMI 29.3 kg/m² IQR 8.7). Half of the participants had seen a podiatrist (52.8%), and 36.5% did not see any other health professional prior to orthopaedic referral. Sixty-five (27.9%) had not yet been given a diagnosis. BMI was positively associated with foot/ankle pain severity (β 0.48, 95% CI 0.05, 0.92), while HRQoL had a negative association (β - 0.31, 95% CI -0.45, - 0.18). Participants told by their GP that they may need an operation were significantly more likely to consider surgery necessary (OR 31.41, 95% CI 11.30, 87.35), while older people were less likely (OR 0.94, 95% CI 0.90, 0.98).

Conclusions

More than one-third of the participants had not accessed allied-health care prior to specialist orthopaedic referral. Participants may consider their GPs opinion on the necessity of surgery compelling, and most expected to undergo surgery, but many couldn't report their diagnosis. The discordance between the expectation of surgery and historically low surgical conversion rates suggests more work is necessary to improve the management of this group.

Relationship between lower-extremity defects and body mass among polish children: a cross-sectional study

BACKGROUND

Lower extremity defects in healthy children raises interest of researchers as confirmed by numerous published original and review articles. The relationship between lower extremity postural defects and body mass are unclear as published data are inconclusive. The aim of the present cross-sectional study was to analyse the prevalence of lower extremity defects in a large group of 8- to 12-year-old children; and further to assess the probability of defects associated with values of body mass variables.

METHODS

The study included prospective anthropometric measurements data of 6992 children (3476 boys and 3516 girls) from Gdansk (Northern Poland). Standard screening test used in Poland for assessment of lower limb defects were used (intermalleolar or intercondylar distance for knee alignment, linear vertical compass for valgus heel, computer podoscope or classical footprint and measuring the Sztriter-Godunow index for flatfeet). Body mass was assessed with local centile charts and IOTF cutoffs. Prevalence of postural defects was compared with an aid of Pearson's chi-squared test and Fisher's exact test. Probability of lower extremities postural defect was estimated on the basis of logistic regression analysis, and expressed as an odds ratio (OR) and its 95.0% CI.

RESULTS

The study demonstrated that cumulative prevalence of lower extremity defects (31.5%) was lower than reported in most published studies, most common defects were valgus heel (21.8%) and valgus knee (14.5%). Boys were significantly more frequently diagnosed with lower limb defects overall (p < 0.001), as well as with varus knee, valgus heel, flatfoot of any degree. Limb defects were found in 90,2% of obese children, 25,7% of normal weight and 15,1% of underweight children.

CONCLUSIONS

Prevalence of some lower extremities defects seems to be sex specific. Prevalence varied across body weight categories and was rising with the increase of BMI. Increased body mass is correlated with a higher risk of developing lower extremity postural defects in children.

Increasing Physical Activity Might Be More Effective to Improve Foot Structure and Function Than Weight Reduction in Obese Adults

Obesity is reported to be an important factor affecting foot structure and function. For obese individuals, weight reduction or increasing weight physical activity could be an effective approach to improve foot structure and function. The present study sought to determine the effect of weight reduction and increasing physical activity on foot structure and function in obese Japanese and to investigate which intervention is more beneficial. The participants were divided into the weight reduction group (n = 30; body mass index 29.0 ± 2.5 kg/m²), with the intervention consisting of dietary modification, and the increasing physical activity group (n = 15; body mass index 28.2 ± 3.1 kg/m²), with the intervention consisting of walking and jogging. A 3-dimensional foot scanner was used to measure the foot anthropometric data with the participants both sitting and standing. The dorsum height declined and the arch stiffness index increased after the weight reduction intervention, and the truncated foot length decreased and the arch stiffness index increased after the increasing physical activity intervention (p <.05). The arch height index showed a downward trend after the weight reduction intervention (p = .060) and an upward trend after the increasing physical activity intervention (p = .069). Moreover, a greater change was found in the increase of the dorsum height and arch height index and decrease of the truncated foot length in the increasing physical activity group than in the weight reduction group (p <.05). These findings suggest that increasing physical activity might be more effective to improve foot structure and function than weight reduction in obese adults.

Central adiposity and mechanical, perceptual and physiological loading during long duration, repetitive lifting

BACKGROUND

There is an absence of information regarding the impact of central adiposity on loading during long duration, repetitive lifting, and very limited information of the impact of elevated body mass on mechanical loading of the lumbar spine. This information is important in evaluation of the validity of injury prevention standards and interventional approaches in this segment of the population.

METHODS

This study evaluated the mechanical, physiological, and perceptual loading during repetitive lifting in participants with central adiposity compared to participants with normal body mass index. Videography, accelerometry, heart rate and perceived exertion measures were used to examine alternations in kinematic, kinetic, and exertional parameters during a 1-hour lifting task (3 × 20-min sets; 4 lifts/min; self-selected mass).

FINDINGS

Low back torque [+69.1 (11.5) Nm], compressive force [+1036.6 (153.6) N] and heart rate [+7.0 (3.5)%] were substantially elevated in participants with central adiposity, however perceived exertion and self-selected mass did not differ between groups. With central adiposity a compensatory mechanism was observed, involving a reduction in trunk vertical displacement [-5.8 (1.9) cm], hip flexion [-6.4 (3.1) deg] and lower-trunk flexion [-10.0 (2.7) deg], which attenuated expected increases to work [9.8 (2.3)%], power [9.5 (4.0)%] and physiological effort.

INTERPRETATION

While mechanical loading increases secondary to elevated body mass are expected, these results provide new insight into origins of such increases for individuals with a central adiposity somatotype. The differences in mechanical, physiological and perceived loading support provision of individual-specific injury prevention strategies, as well as revision of existing mechanical- and physiological-based ergonomic standards.

Impact of rocker sole footwear on plantar pressure distribution during standing and walking in adult obese women

Purpose: Obesity increases the stresses applied to the foot. Ergonomic rocker sole shoes increase energy expenditure of standing and walking in obese individuals but could potentially alter plantar pressure distribution. The aim of this study was to compare plantar pressure distribution during standing and walking between rocker sole and flat-bottomed shoes in obese subjects.Methods: Twenty adult obese women were asked to stand quietly and to walk at their preferred walking speed whilst wearing flat-bottomed or rocker sole shoes. Plantar pressure distribution was assessed using instrumented insoles.Results: During standing, toe pressure and as well as midfoot force were higher with rocker sole than with flat-bottomed shoes (p < 0.05). During walking with rocker sole shoes, mean pressure and maximal force were lower under the toes and the forefoot, but higher under the midfoot and rearfoot regions with respect to flat-bottomed shoes (p < 0.05).Conclusions: While standing with rocker sole shoes, obese subjects showed augmented pressure under the toes whereas forefoot and heel pressure had no significant difference compared to the flat-bottomed shoes. As walking with rocker sole shoes resulted in decreased forces and pressures under the forefoot but increased overload at heel and midfoot regions, obese individuals may not benefit from wearing rocker sole shoes during walking, at least from a plantar pressure distribution perspective.Implications for rehabilitationThe use of ergonomic rocker sole shoes causes a redistribution of in-shoe plantar pressures leading to potentially detrimental adjustments that fail to attenuate the obesity-related increase in midfoot pressure during standing, while accentuating this region-specific impairment in dynamic conditions.Rocker sole shoes may best be avoided for walking in obese patients with heel pain or with any midfoot/rearfoot alteration such as medial arch flattening.